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has a serious dangerous diagnosis or is at risk of
adverse event if not provided inpatient services. In
these circumstances the UR physici an examines
the evidence for clinician’s risk stratification.
Inpatient admission is medically necessary if the
findings are consistent with the patient being at
risk of suffering an adverse event if treated by
outpatient rather than inpatient level of care.
Risk Stratification
The level of evidence for the physician’sriskstratification can range from very formal risk stratification systems to those based on judgment by
experts. When there is a formal, evidence-based,
nationally recognized system that is the most reliable approach. An example of a formal, evidencebased, nationally recognized risk stratification
system is the ABCD2 risk stratification for transient ischemic attacks (TIAs)
1
(Table 19.1). The risk
of suffering a stroke within days is proportional to
the score with moderate to high risk if the score is
4 or more. Less reliable evidence for risk stratification than the use of evidence based guidelines from
national societies and other evidence in the literature is by appropriate physicians and leadership in
the health care institution to form an institutional
consensus. An example of such a consensus is the
CP risk stratification in Table 19.2 derived from
the American College of Cardiology guidelines and
from the TIMI score.
2
For many clinical situations
there is no formal risk stratification system in
existence and in such circumstances the physician
makes a judgment on what is the patient’smost
likely disease and what is the risk to the patient.
Clarity in the physician’s documentation is
important for those performing the UR review
for evidence for medical necessity and more
importantly for working to improve the accuracy
of the risk stratification.
The goal of the physician’s risk stratification
is to accurately place the patient in the correct
level of care. With many patients it is clear after
their initial evaluation that they need acute care
Table 19.2 Cardiac Risk Score Tool for Possible ACS
Nondiagnostic EKG Changes (1 point)
EKG ST segment changes ( < 1 mm ST seg
change)
or T wave changes or LBBB
Age/Sex (1 point)
(Male > 45 years old; Female > 55 years old)
Past History CAD (2 points)
(Angina or PCI or Coronary surgery or MI)
Cardiac Risk Factors (up to 5 points)
Family history of CAD
Hyperlipidemia
Diabetes mellitus
History of smoking
Hypertension
Chest Pain (up to 3 points)
Substernal
Exercise related
Relieved with NTG
Chest Pain Equivalent (up to 4 points)
Syncope
SOB/dyspnea
Rapid heart beat
Unexplained weakness
ADD UP TOTAL# POINTS ABOVE:
__________________________________
(Each Risk Factor counts as 1 point except Past
History CAD = 2 points)
Table 19.1 ABCD2 TIA Risk Stratification Score
Age 60 Yes
+1
BP 140/90
initial evaluation
Yes
+1
Clinical Features
of the TIA:
Unilateral weakness +2
Speech disturbance +1
Other Symptoms +0
Duration of
Symptoms
< 10 minutes +0
10–59 minutes +1
60 minutes +2
Diabetes Mellitus
in Patient’s History
Yes
+1
Level of Care Determination
022
20:42:52
hospitalization and with others it is clear they are
safe to release home. But with some it is not clear
whether or not they have a serious condition and
observation is a tool to clarify their diagnosis.
Observation is appropriate for those whom the
physician judges as having some risk/probability
of disease and observation is needed to clarify
their situation (threshold for observation). Observation is not appropriate for those who have
moderate to high risk/probability of disease and
need inpatient hospitalization (threshold for inpatient admission).
References
1) Johnston SC, Rothwell PM,
Nguyen-Huynh MN, et al.
Validation and refinement of
scores to predict very early
stroke risk after transient
ischaemic attack.
Lancet 2007;369(9558):
283–292.
2) Scott Wrig ht R, Anderson JL,
Adams CD, et al. Table 6 and
Table 7 of 2011 ACCF/AHA
Focused Update incorporated
into the ACC/AHA
2007 Guidelines for the
Management of Patients
with Unstable Angina/
Non–ST-Elevation
Myocardial Infarction. JAm
Coll Cardiol,2011;57:
215–367.
Louis Graff IV
022
20:42:52
Part III
Chapter
20
New Developments in Observation Medicine
Accountable Care Organizations
Kayur V. Patel, MD, FACP, FACPE, FACHE, FACEP
Igor Kozunov, MBA, MHA
Introduction
Accountable Care Organizations (ACOs) are the
future of our health care landscape, and for
Observation Medicine (OM), the future is very
bright. The demand for efficiency and improved
outcomes placed on ACOs will give rise to Observation Units (OUs) where patient–physician collaboration will be improved, acute testing will be
provided timely and accurately, and care coordination and efficiency will rule the day. Hospitals
of tomorrow will look drastically different to
insiders from the way they do today and OM will
be at the forefront of the upcoming changes.
Accountable Care Organizations Aim
to Disrupt the Health Care Industry
ACOs are poised to disrupt the medical industry
and change medical care as we know it. Such is
the hope of those who believe that poor care
coordination is at the center of our health care
woes. To proponents of better care coordination,
an ACO is the long-awaited panacea. ACOs are a
force that will finally make health care organizations care about efficiency and outcomes. A policy
that will realign financial incentives and teach
providers to do better rather than doing more.
One thing is certain – if these hopes come true,
the coming changes will thrust OM front and
center as a prominent force that will help lead
many hospitals to salvation.
So What Exactly is an ACO?
Since the 1970s, one of the scariest three-letter
acronyms in Medicine was HMO (Health Maintenance Organization). This failed policy invention is blamed for much modern anguish. Its
legacy is a jaded medical community trained to
distrust any policy innovation, however wellintentioned it may be.
Upon its first introduction, the vague concept
of an ACO set off countless alarms as cynical
physicians suspected ACOs of being a poorly
concealed attempt at reviving the HMO formula.
Even ACO’s origins resembled those of HMO.
Both are policy inventions, introduced by inventive policy entrepreneurs. In the case of ACO, we
have Dr. Elliott Fisher to thank.
Dr. Fisher, the Director of the Center for Health
Policy Research at Dartmouth Medical School, introducedtheconceptofanACOin2006inadiscussion
with the Medicare Payment Advisory Commission.
The new term remained out of the spotlight until
it was adopted and popularized by politicians
jockeying for a federal health care overhaul.
In 2010, only 4 years after its inception, the
once-vague term became a reality. Signed into law
as part of the Patient Protection and Affordable
Care Act in 2010 by President Obama, ACOs took
aim at business-as-usual in health care.
Centers for Medicare and Medicaid Services
(CMS) describes ACOs as “groups of doctors, hospitals, and other health care providers, who come
together voluntarily to give coordinated high quality care to their Medicare patients.”
1
CMS continues, “The goal of coordinated care
is to ensure that patients, especially the chronically ill, get the right care at the right time, while
avoiding unnecessary duplication of services and
preventing medical errors.”
1
For skeptics, ACO’s founders clearly outlined
the difference between an HMO and an ACO in
the latter's three core principles:
ACOs must be provider-led organizations
with a strong bas e of primary care that are
collectively accountable for quality and total
per capita costs across the full continuum of
care for a population of patient s;
Payments to ACOs need to be linked to
quality improvements that also reduce overall
costs; and
023
20:42:58
ACOs must use reliable and progressively
more sophisticated performance
measurement, to support improvement and
provide confidence that savings are achieved
through improvements in care.
2
Since the signing of the Act by President Obama,
the medical community waited in tense anticipation. Finally, a year after the passage, ACO guidelines were finally issued in March 2011. Another
year later, the first ACOs were approved by CMS
in early 2012.
What the First ACOs Look Like
As of the writing of this chapter, Medicare
announced its first 27 ACOs (150 additional
ACO applications are pending). These early ACOs
fall somewhere between what ACO cheerleaders
and naysayers have been predicting. It is now clear
that the concept was not dead-on-arrival, as some
naysayers believed. Hundreds of hospitals and provider organizations are putting forth the time and
the effort needed to join the ranks of ACOs. Yet,
most organizations are being careful and not quick
to move in, in contrast with the rosy predictions
painted by ACO cheerleaders.
The majority of these early ACOs are surprisingly small. Many are barely over the required
5,000-patient threshold. Of the 27 first ACOs, only
10 are hospitals. The rest are smaller, physician-led
organizations.
3
What these early ACOs demonstrate is that
health care organizations are taking the aims of
CMS seriously. In the process, new strategies to
improve care coordination and efficiency are
being evaluated. Among them is the growing field
of OM.
ACOs are Poised to Fuel Growth of
Observation Medicine
For the world of OM, ACOs are set to fuel an
unprecedented growth of the profession. It is clear
to even the most skeptical observer that only a
substantial improvement in inpatient care efficiency and outcomes will separate successful ACOs
from the losers. OM is one of the few specialties
prepared for the upcoming evolution of inpatient
care and its practitioners are already being viewed
by aspiring ACOs as key drivers of ACO strategy.
The early ACOs eased many fears among the
skeptics. The anticipation that ACOs were going
to be largely driven by hospitals failed to materialize thus far. Most early ACOs are physiciandriven. The regulators are also being serious
about anticompetitive concerns. Stark laws have
not been loosened and hospitals were not given an
opportunity to gobble up market share under an
ACO banner.
The regulators made it clear that they are
serious and the bar has been set high. ACOs
cannot avoid downside risk and have to be all
the way in or out. For those who choose to participate, the only way to make an ACO a profitable proposition is to meet CMS’s goals.
CMS put in place 33 measures to determine
whether participating ACOs earn their rewards.
4
Among these measures is a strong focus on Care
Coordination and Patient Safety. As new ACOs
search for ways to address these measures and
meet CMS's benchmarks, OM is presented with
a rare opportunity for professional intrapreneur-
ship – an opportunity to craft a solid value prop-
osition for the field and to solidify its central role
in the growing ranks of ACOs.
Observation Units Become Crucial
Components of ACO Strategy
By now, it is evident that private insurance companies will soon join the Federal Government in
supporting ACOs. Together, they are poised to
create a perfect storm that will force health care
organizations to shift away from the traditional
“do more–bill more” culture.
Today, many hospital business models can be
described simply as “keeping their beds full.”
However, as financial incentives shift away from
care volume and toward better outcomes and
efficiency, the newly formed ACOs will find that
keeping patients out of the hospital has become
more profitable.
Faced with this new reality, health care executives are reconsidering their assumptions about
how their organizations will make money in the
future. One shift that is already taking place is the
slow death of a general hospital bed. Traditionally, a full bed meant revenue and a reasonable
margin for most hospitals. This assumption is
being undone by CMS guidelines and an ACO's
ability to prevent avoidable hospitalizations will
soon separate the winners from the losers under
the new model. Yet, many hospitals are full of
excess general beds and their mere presence can
Kayur V. Patel and Igor Kozunov
023
20:42:58
often lead to an overuse of hospital's resources,
regardless of the community's true needs.
5
Enter
an OU – the ACO's guard against avoidable hospitalizations and medical errors.
Designed for the strategic aims of their parent
ACOs, OUs facilitate patient-physician interaction, rapid acute testing, and care coordination.
The results of the growth of such units will
include more efficient care, speedy testing and
discharges, improved patient-physician collaboration, and focused care coordination – all gradually closing the traditional fault lines that are
common in many community hospitals.
In the drive toward ACOs, OUs will change
the entire landscape of a community hospital.
Hospitals of tomorrow will no longer possess
massive inventories of general beds. Most will
consist of three main hubs: the Emerg ency
Department, Intensive Care Units, and Observation Units. While all hospital departments will be
affected by the ACO model, some of the most
dramatic results will be driven mainly by Observation Medicine – the field that is no longer ahead
of its time and whose practitioners will help
bridge the gap between hospitals of today and
our collective vision for tomorrow.
1. Centers for Medicare and
Medicaid Services. Accountable
Care Organizations [homepage
on the Internet]. Available
from www.cms.gov/Medicare/
Medicare-Fee-for-ServicePayment/ACO/index.html?
redirect=/aco/ (Accessed
February 2016)
2. McClellan M, McKethan A,
Lewis J, et al. A national
strategy to put accountable care
into practice. Health Affairs,
2010; 29(5):982–990. Available
from http://
content.healthaffairs.org/
content/29/5/982 (Accessed
February 2016)
3. Centers for Medicare and
Medicaid Services. First
Accountable Care
Organizations under the
Medicare Shared Savings
Program. Fact Sheets. 2012.
4. Medicare Program; Medicare
Shared Savings Program:
Accountable Care
Organizations, final rule. 76
Fed. Reg. 212 (2012).
5. Goodman D, Grumbach K.
Does Having More Physicians
Lead to Better Health
System Performance? Journal
of the American Medical
Association, 2008; 299(3):
335–337.
Accountable Care Organizations
023
20:42:58
Part III
Chapter
21
New Developments in Observation Medicine
Acute Medicine in the United Kingdom
Louella Vaughan, MBBS, MPhil, DPhil, FRACP
The context of Observation Medicine in the United
Kingdom is internationally unique due to the recent
development of Acute Medicine as a subspeciality
branch of General (Internal) Medicine. This chapter will provide a brief overview of Acute Medicine
in the UK, its links with British Emergency
Medicine, and its role in Observation Medicine.
Overview
Acute Medicine was developed in the UK as a
response to concerns about patient safety, the
increasing numbers of medical hospital admissions, and the emergence of new treatments where
timeliness is crucial to success.
1
Its rapid spread
and integration into the fabric of the National
Health Service, however, was driven by the “four
hour rule,” a governmental performance target
introduced in 2003/4 which mandated that 98%
of patients presenting to an Emergency Department (ED) must be seen, treated, and then admitted or discharged in under 4 hours.
2
There are
now over 210 Acute Medical Units (AMUs) in the
UK, which manage the majo rity (90%) of emergency medical admissions to hospital for the first
48–72 hours of stay. (See Chapters 16 and 17 on
Extended or Complex Observation.)
Due to the rapid growth of the discipline,
there is a high degree of variability across AMUs.
3
However, the units essentially form an intermediate area between the ED and the downstream
wards with an appropriate allocation and organization of resources to manage the medically
unwell patient. As a result, AMUs share features
of both EDs and general medical wards. The ideal
unit, as outlined in the Royal College of Physician’s Acute Medicine Guidelines,
4
comprises a
separate ‘trolley area’ for the further assessment
and immediate treatment of patients, a highdependency area for Level One and Two care,
bedded bays, a small clinic area for outpatients,
and allied health assessment facilities. Although
AMUs and EDs are ideally co-located, most units
accept patients only via referral from the ED or a
General Practitioner, with the ED retaining the
task of primary assessment and triage of unscheduled emergency patients. Staffing in the units is
multidisciplinary, with dedicated support from
physiotherapy, occupational therapy, pharmacy,
and other allied health staff. These broadly skilled
teams are capable of not only delivering appropriate care to those patients with life-threatening
illnesses, but also arranging and facilitating the
early supported discharge of patients with less
severe illness but complex needs.
The fact that Acute Medicine is a relatively
new speciality has led to a particularly strong
emphasis on patient safety and operational organization. Specialist soc iety standards for AMUs
4, 5
refer specifically to the need for the rapid assessment of patients, the use of early warning scoring
systems, ready access to diagnostic services, and
timely and coordinated discharge planning. The
use of key performance indicators to monitor unit
performance, such as mortality and morbidity
data, discharge and readmission rates, and patient
experience, has been strongly encouraged and will
be soon be governmentally mandated.
The extent to which AMUs have taken on the
task of Observation Medicine varies from hospital
to hospital and is dictate d by local circumstances.
Many larger hospitals or those where the AMU is
not co-located with the ED will often also have
traditional ED-led Observation Units (OU) or
Clinical Decision Units (CDU). (See Chapter 1
[clinical] and Chapter 2 [administrative] on observation medicine.) Some hospitals have shared
observational space, to which the ED, medical
and/or surgical teams can place patients. Decisions about which unit is most appropriate for
any given patient are usually governed by considerations regarding potential risk, rather than
024
20:42:58
being tightly defined by condition. For example,
many hospitals have a single protocol for chest
pain, with the stipulation that those with
low risk pain are admitted to the OU, those with
intermediate or high risk to the AMU and
those with very high risk directly to the Cardiology service. Similarly, patients with non-lifethreatening overdoses tend to be cared for by
EDs where the facility exists, with only serious
or life-threatening overdoses being transferred
for full inpatient care.
The size and nature of AMUs means that they
are able to admit a broad range of conditions for
observation, such as chest pain, deep venous
thrombosis, rule-out pulmonary embolism, spontaneous pneumonthorax, pleural effusion, and
cellulitis. In many AMUs, the care pathways
include ambulatory components. It is usual care,
for example, for a patient with suspected deep
vein thrombosis to be treated predominantly as
an outpatient, with the patient receiving his or her
initial assessment and follow-up via the AMU
before transitioning to full outpatient care. Similarly, AMU pathways for cellulitis often stipulate
that patients are administered intravenou s antibiotics for 24–48 hours, with poorly responding,
but otherwise well patients then being transferred
to an ambulatory pathway for ongoing intravenous antibiotics. Some patients return daily to the
units for antibiotic administration, while others
have nurses give their antibiotics at home with
weekly medical review on the AMU. The multidisciplinary nature of the staffing also means that
elderly patients, such as those with falls, can often
be seen, rapidly assessed, and then discharged
with increased or interim packages of care, thus
avoiding lengthy inpatient stays.
Outcome
Although AMUs are almost ubiquitou s throughout the UK, only a relatively small number of
units have published before-and-after studies in
peer-reviewed journals and only one unit has
performed any economic modelling.
6
Two studies
reported significant reductions in inpatient mortality; four studies found significant reductions in
length of stay between 1.5 and 2.5 days; and eight
studies described improvements in various
aspects of hospital functioning, such as reductions
in the numbers of emergency patients awaiting
inpatient beds and improved patient triage to
inpatient specialties. The no n-peer-reviewed literature supports these findings.
The success of the model in the UK has led to
its adoption in Australia, New Zealand and the
Netherlands. Eight non-peer-reviewed reports of
48 units in Australia and New Zealand confirmed
almost uniform reductions in length of stay (0.4
to 3.0 days), although a number of hospitals
reported small increases in readmission rates.
Conclusion
Acute Medical Units have been a highly successful
innovation in the United Kingdom, with rapid
diffusion of the units throughout the UK. They
have been shown to reduce length of stay, promote safe patient care, and improve other aspects
of hospital functioning. With regard to observation medicine, many AMUs perform the same
function as ED-led OUs, with patients being
admitted for up to 48 hours for observation.
A key point of difference, however, is the ability
of AMUs to provide ongoing ambulatory care for
patients.
References
1. Federation of Medical Royal
Colleges. Acute medicine:
the physician's role. Proposals
for the future. A working
party report of the
Federation of Medical
Royal Colleges. London:
Royal College of Physicians;
2000.
2. Alberti G. Transforming
Emergency Care in England.
Department of Health,
London; 2004.
3. Ward D, Potter J, Ingham J,
et al. Acute medical care. The
right person, in the right
setting–first time: how does
practice match the report
recommendations? Clin Med
2009;9(6):553–6.
4. Royal College of Physicians of
London. Acute medical care:
the right person, in the right
setting — first time. Report of
the Acute Medicine Task Force.
RCPL, London; 2007.
5. Royal College of Physicians of
Edinburgh. RCPE UK Consensus
Statement on Acute Medicine.
RCPE, Edinburgh; 2008.
6. Scott I, Vaughan L, Bell D.
Effectiveness of acute medical
units in hospitals: a systematic
review. Int J Qual Health Care
2009;21:397–407.
Acute Medicine in the United Kingdom
024
20:42:58
Part
IV
Clinical
12:24:49
Subpart IVA
Chapter
22
Clinical – Cardiac
Chest Pain
Tertius T. Tuy, MD
W. Frank Peacock, MD, FACEP
Background
With 5.5 million patients per year presenting with
chest pain (CP),
1
it is the second most common
nontraumatic complaint to the emergency department (ED) after abdominal pain.
2
While a large
proportion of patients with CP will ultimately be
diagnosed with noncardiac pathology (gastrointestinal, pulmonary, psychiatric, etc.), up to
50% may have cardiac-related CP.
3
Because CP
of cardiac origin can result in precipitous adverse
outcomes, it is commonly the focus of prolonged
evaluation. While this chapter will focus on the
approach to the evaluation of CP that is potentially cardiac in origin, care should be given to
consider alternative etiologies. Some of the most
feared causes of acute CP are pulmonary embolus,
pneumothorax, cardiac tamponade, aortic dissection, and acute coronary syndrome (ACS).
Among these, ACS may be difficult to rule out
in the ED setting, and may require a prolonged
period of time to be effectively excluded. Thus
observation units (OUs) are utilized providing
an intermediate and supervised placement for
patients requiring further evaluation.
4
Since the clinical examination alone can rarely
include or preclude the possibility of ACS, reperfusion therapy is heavily dependent on electrocardiograms (ECGs) and serial cardiac biomarker
investigations. Without serial evaluations about
5% of patients with ACS could be misdiagnosed
and potentially inappropriately sent home from
the ED, which is associated with an increased
mortality rate.
5,6
In order to prevent missed acute
myocardial infarctions (AMIs), the American
Heart Association and American College of Cardiology (AHA/ACC) have recommended that
potential ACS patients should be observed for a
short period of time while having serial cardiac
biomarker testing, diagnostic imaging, and in
some cases, provocative stress testing.
7
OUs provide a location for patients to
undergo these investigations. As reported in the
Chest Pain Evaluation Registry (CHEPER), OUs
have a miss rate of 0.4%, while EDs without an
OU have a miss rate of 4.3%.
8
Furthermore, for
patients with undifferentiated or atypical CP
without diagnostic ECGs or cardiac biomarkers,
the current guidelines from the American College
of Cardiology and the American Heart Association suggest that these patients be evaluated in
an OU.
4
OUs have been shown to decrease missed MI
rates, reduce length of stay (LOS), decrease costs,
and improve patient satisfaction while maintaining equivalent or better patient outcomes. One of
the earliest studies (data collected in 1993–1995)
documented a decrease in the hospital admission
rate, total cost, and LOS for an accelerated diagnostic protocol in a CP OU.
9
In this study, the
mean total cost per patient was $1,528 for CP OU
vs. $2,095 for inpatients (p < 0.01), and the mean
LOS (in hours) was 33.1 for the CP OU vs. 44.8
hours (p < 0.01).
9
Likewise, other more recent
analyses comparing CP OU to hospital admissions have demonstrated a decrease in both
the number of admissions (54% vs. 37%) and
the number of ACS patients discharged (14%
vs. 6%), an increase in quality of life (at 6 months
following treatment), and a decrease in costs of
management
10
(all without changing the rate of
cardiac events).
11
Newer technology using cardiac
MRI in the OU reduced median hospitalization
cost by $588 (95% CI $336 to $811) compared to
inpatient strategy for patients with emergent nonlow-risk CP.
12
Another study compared an ED
CP patients were converted to full inpatient
admission from the ED OU: 7.9% vs. 19.2% of
the in-hospital OU (p < 0.0001), and that the ED
OU was more cost effective than the inpatient
OU. The mean cost per patient for the ED OU
025
20:47:21
was $889.87 (95% CI 862.8–916.9), while the
inpatient OU totaled $1039.70 (95% CI
991.7–1087.7O).
13
Other studies have found similar evaluation
and outcome improvements. In the rule out myocardial ischemia (ROMIO) trial, a rapid ED-based
rule out protocol was compared with routine hospital care. The rapid ED protocol patients had a
shorter hospital stay (median 11.9 vs. 22.8 hours,
p = 0.0001) , lower initial ($893 vs. $1,349, p =
0.0001), and 30-day ($898 vs. $1,522, p = 0.0001)
hospital charges than the patients with routine
care.
14
Another study that compared patients
admitted to a short stay unit with patients admitted as inpatients found similar results.
15
Patients
eligible for admission to the OU were either
admitted to the hospital in various units or to
the OU. The median total costs at 6 months was
significantly lower for the OU ($1,927) than for
patients admitted to the wards ($4,712), stepdown or intermediate care units ($4,031), or coronary care units ($9,201); although the cost was
higher than for an ED visit ($403) (p < 0.0001).
Moreover, the rate of major complications, recurrent myocardial infarction or cardiac death
during the 6 months after the initial presentation was similar for those in the OU vs. those
who were inpatients.
15
These findings have not been limited to the
United States. The Effectiveness and Safety of
Chest Pain Assessment to Prevent Emergency
Admission (ESCAPE) trial, a British study, demonstrated improved health utility at follow-up in
the CP OU patients vs. inpatients. This was simi lar to the aforementioned studies done in the
United States. The proportion of admitted
patients decreased from 54% to 37% (p <
0.001), and the proportion discharged with ACS
decreased from 14% to 6% (p = 0.264). Rates of
cardiac events were unchanged. There was a
saving of £78 per patient (p = 0.052). More
importantly, there was a significant (p = 0.022)
improved health utility during follow-up with
0.0137 quality-adjusted life years gained. From
this analysis, the authors concluded that “Care
in a chest pain observation unit can improve
outcomes and may reduce costs to the health
service. It seems to be more effective and more
cost effective than routine care.”
11
The OU may offer improved patient satisfaction in low-risk CP patients compared to standard
hospitalization.
11
The Chest Pain Evaluation in
the Emergency Room (CHEER) study randomly
assigned 424 patients with unstable angina to
either a routine monitored bed under the care
of the cardiology service (N = 212) or to the CP
OU located in the ED under a stric t protocol
(N = 212). There was no significant difference
in the rate of cardiac events between the two
groups during the hospital stay (Odds Ratio
[OR] 0.5 CI 0.19–1.29, p = 0.15), 30 days after
discharge (OR 0.5 CI 0.2–1.24, p = 0.13), or
event-free survival over 180 days (p = 0.58).
16
There were 15 primary events in the hospital
admission group (13 myocardial infarction
[MI], 2 congestive heart failure [CHF]) and only
7eventsintheEDOUgroup(5MI,1CHF,
1 death from cardiovascular causes). Resource
use during the first 6 months was greater among
the hospital admission group than among those
intheEDOUgroup(p< 0.01).
16
Thus the preponderance of the literature suggests that CP OUs are a safe and effective means
of evaluating patients at low to intermediate risk
of ACS. By providing an intermediate location for
further care and evaluations, their use has alleviated an unnecessary financial burden on the
patient and medical care system associated with
unwarranted hospital admissions. At the same
time it has similar rates of adverse events as those
admitted to the hospital.
17
Pathophysiology
CP associated with ACS is caused by myocardial
ischemia from inadequate oxygen perfusion
(oxygen supply relative to demand). Coronary
artery disease predisposes patients to plaque rupture, and subsequent occlusion of the coronary
vessels by platelet activation and thrombus formation. Ischemia and myocardial infarction
leads to aberrations of the conduction system
and/or the release of cellular components, which
manifest as electrocardiographic or cardiac biomarker changes. The evaluation and management of patients with suspected ACS starts with
the e arly detection of cellular injury with an
electrocardiogram or cellular necrosis by cardiac
biomarkers.
Risk Stratification
Classically, patients with pain consistent with
ACS suffer from a substernal, crushing pain or
pressure which lasts > 20 minutes. The pain may
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